How to succeed on surgery clerkship/rant

[Skarl]

MS3 interested in a surgical subspecialty currently on the core clerkship.

I feel like there is a huge disconnect between succeeding on the surgery clerkship vs. actually matching into a competitive surgical field. To match you need to publish lots of research in the field, connect with mentors who'll go to bat for you, and ace your shelves/STEP 2CK which is largely clinical reasoning. Versus on the clerkship itself sometimes I feel like incentives are completely different. For example you're told to study your patients' history and case anatomy but during the surgery no one expects you to know or asks you about these (rarely some attendings will engage students more) or you learn a lot about management of surgical problems in shelf studying but on rounds you just regurgitate <min presentations and have your plan corrected by your resident because you have no idea what post-op management should look like because all of your preclinical teaching seemed catered toward medicine and you've never followed patients post-op before. You don't have a clear role in the OR (often attending with resident +/- fellow or another attending for big cases) or on the floor (mostly run by residents/midlevels). You practice until you can suture a solid running subcuticular but then how much you do is completely random and depends on your chief/attending and/or if you make one mistake with your resident breathing down your shoulder now it looks like you didn't practice enough.

I feel like surgery is 10000% better as a resident with actual responsibilities and when you can focus just being a good surgical resident instead of being that and a good student, as the two are almost non-overlapping. Any high yield tips from people who did well on their clerkship, specifically re:

1. Resources for studying anatomy? I feel like you can go down deep rabbit holes for each case but I want to know enough to know what's going on generally and answer pimp questions.
2. Tips for AM rounds surgical presentations?
3. How can I stand out and demonstrate interest in surgery?

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[operaman]

1. YouTube videos prior to any case you don’t already know well. They will often point out relevant anatomy. Then study an atlas and make sure you have a good lay of the land. I love to pimp on anatomy and generally start with easy stuff and move into more esoteric things until they miss one. But YouTube videos are the best. You can watch multiple surgeons do the same case many different ways and then scrub in having a sense of what’s happening.

2. Know more, say less. Every service and chief/attending has different expectations so be flexible, but generally speaking try to know as much as you can about the patient and say as little as is necessary to convey key information.

For example, take a thyroidectomy POD1. What I care about: Drain output (if applicable), calcium level/symptoms of hypocalc, voice/swallowing, and how the neck looks. You go see the patient, do an exam, and they will tell you all sorts of things that aren’t necessarily important. They may recount all of their dinner choices to you, but all you need to relay is “tolerating a regular diet.” As a student you should be a bit more thorough in your exam as well, but maybe reporting their abdominal exam after a thyroid isn’t quite as relevant as it would be after a chole.

A whole student presentation might be: ms Jones is POD1 from a total thyroid. No events overnight, tolerating regular diet, no voice concerns, no symptoms of hypocalcemia. On exam, pt is afebrile and normotensive, voice is strong, neck is soft and incision c/d/i, JP with 20cc of sersang drainage. Ionized calcium level was X. My assessment is that she has met her initial post operative goals. My plan is to remove the drain and discharge her this morning.

I could probably rattle that off in under 20 seconds and I’ve really covered the key points. Note also things I chose to omit, like pain control. I would have looked at her MAR and asked the RN about it and asked her as well, but unless there’s a problem it’s not really figuring into my decision making. If the chief asked about pain I would be ready with number of opioids and Last time they needed IV pain meds, but I wouldn’t necessarily put that in my presentation. This is where “know more, say less” comes into play. Obviously if she was hammering the overnight RN with so many IV dilaudid requests that they paged the overnight resident for more prn orders, then that would figure prominently in my presentation as it would likely alter my plan.

This kind of thinking is very challenging to do as a student because you don’t know what’s important yet. I would certainly struggle if I were to jump on a Gen surg service tomorrow morning, but I would pick things up fast because I know what I’m looking for. My epiphany moment for this came on my OBGYN rotation when we did attending rounds and he would present our patients back to us and ask us what he did differently. He was also the one who for my graded H&P had me see a post op clinic patient and said “this is a simple post op visit. If you are out of that room in under 30 seconds with the key pieces of info, you get honors. Less than a minute is a high pass. 2 minutes is a pass. Anything more is a fail.”

Being a student is hard because nobody thinks you know anything. If I were presenting that thyroid patient to one of my attending partners I’d just say “pod1 thyroid, doing great, sending her home” because we both know what’s important and that I would have checked all those things. Zero chance I believe a student will do that every time so I expect a little more detail. The good students learn how to focus on the key issues.

Once you get that down, you can start to anticipate the pimp questions. Like in that thyroid patient, if you made a nice concise presentation, I would ask you what your plan would be if there were signs of hypocalcemia. Or maybe what you would do if there were a neck hematoma. Top students learn to anticipate and prepare accordingly. Nobody does this from day 1, but it’s a process and the standout students keep getting better.

3. Standing out comes from your presentations, your preparation, and your work ethic. Work ethic you display by taking notes on rounds just like the intern, paying attention, showing up early and finding ways to help, etc. Every student asks “is there anything I can help with?” While the top students ask “it looks like we need to pull ms Jones’ JP drain and do mr smith’s pm dressing change - I’ve done those before; would you mind if I took care of those?” Even if they say no, it still shows you’re paying attention and actually trying to help. Ask to go see consults, to help set up or gather supplies for procedures, etc. Most students just blend into the paint, so offering specific help for things that actually need to be done stands out in a very positive way.

 

[Skarl]

1. YouTube videos prior to any case you don’t already know well. They will often point out relevant anatomy. Then study an atlas and make sure you have a good lay of the land. I love to pimp on anatomy and generally start with easy stuff and move into more esoteric things until they miss one. But YouTube videos are the best. You can watch multiple surgeons do the same case many different ways and then scrub in having a sense of what’s happening.

2. Know more, say less. Every service and chief/attending has different expectations so be flexible, but generally speaking try to know as much as you can about the patient and say as little as is necessary to convey key information.

For example, take a thyroidectomy POD1. What I care about: Drain output (if applicable), calcium level/symptoms of hypocalc, voice/swallowing, and how the neck looks. You go see the patient, do an exam, and they will tell you all sorts of things that aren’t necessarily important. They may recount all of their dinner choices to you, but all you need to relay is “tolerating a regular diet.” As a student you should be a bit more thorough in your exam as well, but maybe reporting their abdominal exam after a thyroid isn’t quite as relevant as it would be after a chole.

A whole student presentation might be: ms Jones is POD1 from a total thyroid. No events overnight, tolerating regular diet, no voice concerns, no symptoms of hypocalcemia. On exam, pt is afebrile and normotensive, voice is strong, neck is soft and incision c/d/i, JP with 20cc of sersang drainage. Ionized calcium level was X. My assessment is that she has met her initial post operative goals. My plan is to remove the drain and discharge her this morning.

I could probably rattle that off in under 20 seconds and I’ve really covered the key points. Note also things I chose to omit, like pain control. I would have looked at her MAR and asked the RN about it and asked her as well, but unless there’s a problem it’s not really figuring into my decision making. If the chief asked about pain I would be ready with number of opioids and Last time they needed IV pain meds, but I wouldn’t necessarily put that in my presentation. This is where “know more, say less” comes into play. Obviously if she was hammering the overnight RN with so many IV dilaudid requests that they paged the overnight resident for more prn orders, then that would figure prominently in my presentation as it would likely alter my plan.

This kind of thinking is very challenging to do as a student because you don’t know what’s important yet. I would certainly struggle if I were to jump on a Gen surg service tomorrow morning, but I would pick things up fast because I know what I’m looking for. My epiphany moment for this came on my OBGYN rotation when we did attending rounds and he would present our patients back to us and ask us what he did differently. He was also the one who for my graded H&P had me see a post op clinic patient and said “this is a simple post op visit. If you are out of that room in under 30 seconds with the key pieces of info, you get honors. Less than a minute is a high pass. 2 minutes is a pass. Anything more is a fail.”

Being a student is hard because nobody thinks you know anything. If I were presenting that thyroid patient to one of my attending partners I’d just say “pod1 thyroid, doing great, sending her home” because we both know what’s important and that I would have checked all those things. Zero chance I believe a student will do that every time so I expect a little more detail. The good students learn how to focus on the key issues.

Once you get that down, you can start to anticipate the pimp questions. Like in that thyroid patient, if you made a nice concise presentation, I would ask you what your plan would be if there were signs of hypocalcemia. Or maybe what you would do if there were a neck hematoma. Top students learn to anticipate and prepare accordingly. Nobody does this from day 1, but it’s a process and the standout students keep getting better.

3. Standing out comes from your presentations, your preparation, and your work ethic. Work ethic you display by taking notes on rounds just like the intern, paying attention, showing up early and finding ways to help, etc. Every student asks “is there anything I can help with?” While the top students ask “it looks like we need to pull ms Jones’ JP drain and do mr smith’s pm dressing change - I’ve done those before; would you mind if I took care of those?” Even if they say no, it still shows you’re paying attention and actually trying to help. Ask to go see consults, to help set up or gather supplies for procedures, etc. Most students just blend into the paint, so offering specific help for things that actually need to be done stands out in a very positive way.

You always have very helpful replies to my threads and others’ and great insights to share. Thank you!

 

[longhaul3]

Agree with post above. I would also offer that your performance on the core surgery clerkship is not that important in your overall match prospects. As long as you get a good grade and do well on the shelf it's just another box checked. The things that matter are sub-i performance and the other things you've already identified. The clerkship is just a few weeks and is as much a chance for you to be exposed to the culture of surgery as anything else.

I spent most of my surgery clerkship on the vascular service and don't remember jack. I just showed up early, stayed late, and said yes. The rest immediately became completely irrelevant to the rest of my training.

Edit: I guess it depends on the subspecialty—if it is a subspecialty of general surgery like PRS or vascular, you probably do need to stand out a little more. If an unrelated subspecialty like ortho, neuro, etc. then the above stands

 

[operaman]

Agree with post above. I would also offer that your performance on the core surgery clerkship is not that important in your overall match prospects. As long as you get a good grade and do well on the shelf it's just another box checked. The things that matter are sub-i performance and the other things you've already identified. The clerkship is just a few weeks and is as much a chance for you to be exposed to the culture of surgery as anything else.

I spent most of my surgery clerkship on the vascular service and don't remember jack. I just showed up early, stayed late, and said yes. The rest immediately became completely irrelevant to the rest of my training.

Edit: I guess it depends on the subspecialty—if it is a subspecialty of general surgery like PRS or vascular, you probably do need to stand out a little more. If an unrelated subspecialty like ortho, neuro, etc. then the above stands

I will add that hospitals are small places and people talk. I was on vascular for my whole clerkship and the faculty definitely talked about me with some ent faculty, so a strong performance can make it’s way around when people talk about strong students. I’ve definitely talked about good students with other people. Things like “hey I just had so and so on my service and he was fantastic. Apparently he wants to do your lame field instead of ent, but dang he’s a rockstar.” As a resident I would often hear about students who were ent bound from other Gen surg residents, for better or worse.

Usually I only talk about students if it’s good. I don’t think it’s fair to trash someone who’s in the process of learning. But I will definitely sing praises when someone was really strong!

The other way Gen surg is relevant to subs is that you can learn a lot of skills and general surgical mindset there so you can shine more on your sub I and aways. Nobody is born knowing this stuff and you have to learn it somewhere. Surg is a great opportunity to learn and grow so you’re ready to shine when the time comes.

 

[srirachamayonnaise]

I will add that hospitals are small places and people talk. I was on vascular for my whole clerkship and the faculty definitely talked about me with some ent faculty, so a strong performance can make it’s way around when people talk about strong students. I’ve definitely talked about good students with other people. Things like “hey I just had so and so on my service and he was fantastic. Apparently he wants to do your lame field instead of ent, but dang he’s a rockstar.” As a resident I would often hear about students who were ent bound from other Gen surg residents, for better or worse.

Usually I only talk about students if it’s good. I don’t think it’s fair to trash someone who’s in the process of learning. But I will definitely sing praises when someone was really strong!

The other way Gen surg is relevant to subs is that you can learn a lot of skills and general surgical mindset there so you can shine more on your sub I and aways. Nobody is born knowing this stuff and you have to learn it somewhere. Surg is a great opportunity to learn and grow so you’re ready to shine when the time comes.

Tbh, I think this whole mentality that I need to constantly impress attendings can be really tedious and toxic. Since I am at a p/f clerkship school, I am really fortunate enough to not feel the need of constant validation. Tbf, no medical student is “fantastic” in surgery and the learning only begins in residency. And once you are in residency, everyone will become competent as long as enough time is put in. Performing a surgery is not the same as playing a piano piece as a virtuoso. Talking behind someone’s back is just lame, be it a praise or a put down. Words get around who likes to gossip behind others back pretty quickly and it’s a bad form for anyone’s career.

 

[operaman]

Tbh, I think this whole mentality that I need to constantly impress attendings can be really tedious and toxic. Since I am at a p/f clerkship school, I am really fortunate enough to not feel the need of constant validation. Tbf, no medical student is “fantastic” in surgery and the learning only begins in residency. And once you are in residency, everyone will become competent as long as enough time is put in. Performing a surgery is not the same as playing a piano piece as a virtuoso. Talking behind someone’s back is just lame, be it a praise or a put down. Words get around who likes to gossip behind others back pretty quickly and it’s a bad form for anyone’s career.

Well as someone who is both a surgeon and a virtuoso pianist, I have to heartily disagree on basically every point you make here.

And no not everyone becomes remotely competent. Not even close. Many trim their practice to what they can really do. Others get it trimmed by their division chiefs. And I know this because just like with students, word gets around about other attendings too. And wouldn’t you know it that I’m just never available to collaborate on a case with certain surgeons because I don’t want to get anywhere near those train wrecks.

The pianist Vladimir Horowitz famously remarked that there are only 3 types of pianists: Jewish, homosexual, or bad. I’m sure there’s a similar analogy for surgeons, and the third type is still “bad.”

 

[srirachamayonnaise]

Well as someone who is both a surgeon and a virtuoso pianist, I have to heartily disagree on basically every point you make here.

And no not everyone becomes remotely competent. Not even close. Many trim their practice to what they can really do. Others get it trimmed by their division chiefs. And I know this because just like with students, word gets around about other attendings too. And wouldn’t you know it that I’m just never available to collaborate on a case with certain surgeons because I don’t want to get anywhere near those train wrecks.

The pianist Vladimir Horowitz famously remarked that there are only 3 types of pianists: Jewish, homosexual, or bad. I’m sure there’s a similar analogy for surgeons, and the third type is still “bad.”

Love the Horowitz comment. I am not a virtuoso pianist per se, but I do find surgical skills a lot easier to master given time.

 

[Angus Avagadro]

Another factor when I dealt with students is , are they Coachable? Meaning, how do they respond to critiquing? How do they respond to the instruction? If they seamlessly alter their approach, this indicates they are someone I can teach. Absolutely agree that the best students say less on rounds, don't raise their hands to answer, but always know the answer when asked. This quiet competence will always get recognized.